Medical adhesive-related skin injury in adult intensive care unit: scoping review

ABSTRACT Objectives: to identify and synthesize scientific evidence on preventing medical adhesive-related skin injuries in adult intensive care patients. Methods: this is a scoping review based on PRISMA-ScR recommendations and the technique proposed by Joanna Briggs Institute. PubMed, CINAHL, Web of Science, Scopus, LILACS, and Embase databases were searched using “Injuries AND Adhesives AND Skin AND Medical” descriptors”. Results: 1,329 studies were identified, and after analysis, the final sample consisted of nine articles. We obtained two experts’ consensus, three case studies, two cross-sectional studies, one prospective cohort study, and one literature review regarding the type of studies. Final Considerations: the synthesized evidence allowed us to list health care measures to prevent medical adhesive-related skin injuries. The professional must know how to identify the skin injuries associated with medical adhesives and the main strategies for their prevention.


INTRODUCTION
Adhesive products are present in many different health care settings and services. In the intensive care unit (ICU), patients use many adhesive devices: monitoring electrodes, catheter fixators, vascular device attachments, endotracheal tube attachments, drains, and dressings. Therefore, critically ill patients are more exposed to medical adhesives and, consequently, an increased risk of adhesive-related skin injuries (1)(2) .
We point out that "medical adhesive-related skin injuries" (MARSI) is a definition of any injury characterized by altered skin integrity, including erythema, laceration, erosion, blister, blebs, and others, that persists for 30 minutes or more after removal of an adhesive product (2) .
The differential diagnosis of MARSI in critically ill patients becomes challenging because some skin injuries may present similar characteristics, called "confounding lesions." Identifying the etiology of the injury is critical for assertive diagnosis and nursing care management (3) . A prospective cohort study included incontinence-associated dermatitis, FI, and MARSI as confounding lesions for pressure injury. The estimated incidence was 35.6% in the intensive care unit setting (4) .
Injuries with common characteristics to MARSI include friction injuries (FI) and moisture-associated dermatitis (IAD). FIs are traumatic wounds that may result from various mechanical forces such as shear or friction forces, including blunt trauma, falls, equipment injury, or adhering dressings removal (5) . Particularly, IAD is a type of moisture-associated dermatitis defined as prolonged skin exposure to effluents, which may be urine, feces, exudate, or sweat, with erythema and edema of the surface, and accompanied by erosion, blisters with exudate, or secondary infection (6) .
In Brazil, epidemiological data on MARSI in adult intensive care unit settings are still scarce. A study conducted in a cardiology ICU showed a prevalence of 22.7% (7) . Worldwide, indicators differ depending on the geographic location. In Beijing, the injuries incidence in two ICUs was 10.96% (1) ; still, in China, a cross-sectional study in four hospitals showed a prevalence of 19.7% in patients with the peripherally inserted central catheter (PICC) (8) ; in the United States, the mean prevalence was 13% in two intensive care units (9) .
MARSI is an adverse event (AE) still not fully recognized by nursing and other health professionals. It is noteworthy that an AE can occur in any setting providing health care; however, its recognition can serve as a basis for decision-making and patient safety planning through analysis, monitoring, minimization, and prevention (10) .
Besides negatively impacting patient care and safety, medical adhesive-related skin injuries can influence the length of hospital stay, increase the period of treatment and its respective costs, and promote risks of infections and complications. Therefore, professionals should be aware of practices for managing medical adhesives and take care of prevention, diagnosis, and treatment (8,11) .
In addition to patients and professionals involved in care, the subject deserves attention from health services managers, who should consider its association with ethical, legal, and financial aspects. In that way, it is essential to explore scientific publications to expand the knowledge about medical adhesive-related skin injuries and, subsequently, about adherence to protocols, aiming at the quality of services provided.

OBJECTIVES
To identify and summarize scientific evidence on preventing medical adhesive-related skin injuries in adult intensive care unit patients.

METHODS
That is a scoping review, a systematic approach to map evidence and identify the main concepts, theories, sources, and gaps in knowledge on a given subject (12)(13) . The research protocol was structured according to the recommendations of the international guide PRISMA-ScR (12) and based on the technique proposed by Joanna Briggs Institute (JBI), which suggests five steps: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies; 4) data analysis; and 5) grouping, synthesis, and presentation of data (13) . That was registered in the Open Science Framework, registration N o DOI 10.17605/OSF.IO/6QKAV.
We used the PCC strategy, P (Population) -adult patients; C (Concept) -medical adhesive-related skin injuries; and C (Context) -intensive care unit to formulate the guiding question, to develop the following research question: What scientific evidence is available in the context of adult intensive care unit to prevent medical adhesive-related skin injury?
The study conducted a preliminary search to identify similar scoping reviews and the primary descriptors and keywords used in studies that addressed the topic of interest. After that analysis, the final search strategy was defined as "Injuries AND Adhesives AND Skin AND Medical" and was carried out in May, June, and July 2021 in the PubMed, CINAHL, Web of Science, Scopus, LILACS, and Embase databases.
The inclusion criteria for the studies' selection were scientific research which published the complete text, in English, Portuguese and Spanish, describing medical adhesive-related skin injuries and their prevention in adult intensive care unit patients. Exclusion criteria were publications in the format of articles, reviews, and letters. At the end of the search, we sent the studies to Rayyan ® , a free application available on the internet, used to assist in research such as review and metaanalysis type, which allows streamlining the initial screening of abstracts and titles.
Three researchers did the initial evaluation of the studies. Initially, the title and abstract of all identified studies were analyzed. Based on the established criteria, the selected studies were read in their entirety to identify health care recommendations for preventing skin injuries related to medical adhesives. The data extracted from the studies were pre-established in the search protocol. A structured instrument identified the literature, with information about the title, study type, year of publication, country of origin, objective, type of research, population, location, description of care for prevention of MARSI, and results.
Those data, plus the classification of the level of evidence (LE), were summarized, grouped, and presented in Chart 1. The classification of the studies' LE was implemented using the classification system recommended by the JBI, as follows: Level 5 (expert opinion), Level 4 (descriptive observational studies), Level 3 (analytical observational studies), Level 2 (quasi-experimental studies), and Level 1 (experimental studies) (14) .

RESULTS
The initial database search generated 1.329 studies: 611 identified in PubMed, 43 in Web of Science, 100 in CINAHL, 217 in Scopus, 13 in LILACS, and 345 in Embase. Three hundred eightyseven studies were excluded due to duplication in the initial screening process, leaving 942 articles for the title and abstract review. After analysis, we selected 38 articles to be read in their entirety. In the end, the sample was composed of nine articles. We detailed that process in the flowchart of Figure 1.

DISCUSSION
As observed, the studies identified do not present high levels of evidence. We want to point out that the discussion on this subject is new. The first international consensus on MARSI was published in 2013 (2) , raising interest in further studies. The concept on the subject is not yet extensively disseminated among nursing professionals. Therefore, it is essential to emphasize the need for more clinical studies to support evidence-based practice.
Nevertheless, the publications mentioned address strategies that consider the approach to MARSI prevention care, such as skin assessment, identification of patients at risk, selection of product, skin preparation, adhesive application and removal techniques, and the continuing training of health professionals.
Assessing the skin is a particularly relevant nursing intervention, mainly in patients exposed to medical adhesives. Studies report that the patients' skin should be evaluated in the admission process, at regular intervals, before and after using adhesive products. During that process, the professional should pay attention to these characteristics: skin integrity, color, temperature, fragility, edema, and signs of local irritation (2,11,17) .
But the detection of risk factors will help professionals identify patients at risk of developing skin injuries. The literature mentions those factors, such as extremes of age, underlying dermatological conditions, some comorbidities (diabetes, renal failure, hypertension, venous insufficiency, among others), skin dryness, prolonged use of corticosteroids, coagulants, dehydration, malnutrition, exposure to moisture, use of adhesive tapes and products (1)(2)7,17) .
The choice of the adhesive product is essential. For that, besides the information collected during skin assessment and the identification of risk factors, it is necessary to consider aspects such as anatomical position, region of movement, exposure or not to moisture, presence of edema, estimated time of adhesive permanence, purpose, and characteristics of each adhesive product (9,11,18) . Before applying the patch, the skin has to be clean and dry, and the hair trimmed if necessary. It should employ skin barrier products because they provide a protective interface between the adhesive and the skin. Furthermore, avoid substances that boost the strength of the patch of the medical adhesive (2,11,16,18) .
Proper application and removal of the adhesive product are paramount to minimize skin damage. The adhesive must be applied without tension and placed with firm and gentle compression, avoiding gaps and folds. During removal, patches can damage the skin and cause pain to the patient, so removal products should be considered because, besides removing adhesive residues and the barrier film, they minimize discomfort and damage to the skin. Furthermore, the appropriate technique recommended for removal is to start it from the edges, slowly, at a low angle, in the direction of hair growth, keeping it horizontally, close to the skin surface (1)(2)11,18) .
Training of health professionals is a crucial strategy for the processes described above. Professionals must be aware of the causes and risks of MARSI and provide proper care to prevent and treat those injuries effectively. We point out that early recognition is critical to ensure appropriate intervention and avoid loss of skin integrity and harm to the patient (2,11,17,19  The articles selected were published between 2013 and 2021. The studies originated from the United States of America (1; 11.1%), United Kingdom (4; 44.4%), China (2; 22.2%), Brazil (1; 11.1%); and 1 (11.1%) was multicenter, including Europe, Australia, and North American countries. Overall, the studies did not have a strong level of evidence: two studies had Level 5 evidence (expert consensus), six studies presented Level 4 (3 case studies, two cross-sectional studies, and one literature review), and 1 study had Level 3 (prospective cohort).
We can describe the primary strategies for MARSI prevention in nursing care through the identified studies. Some medical care repeats itself throughout the articles, so it was possible to group them into categories presented in Chart 2.

Contributions to the field of Nursing
This review contributes to translating scientific evidence into necessary actions in clinical practice. The results presented can support the development of care protocols and guide the actions of nursing professionals, aiming to improve the quality of health care and the safety of patients in critical care who routinely use medical patches. They also reinforce the need to publish studies with a strong level of evidence regarding nursing care to prevent MARSI in the adult intensive care setting.

CONCLUSIONS
During the process of building this scoping review, the lack of studies addressing specifically MARSI preventive measures in the adult intensive care setting was evident. Mostly, there are no recommendations with a high level of evidence; and there is a lack of clinical studies on preventive strategies implemented in intensive care and their respective results. We point out that only one national study was identified, showing that the subject is still little published in Brazil.
The main strategies described in the studies correspond to skin assessment, identifying patients at risk, selecting the adequate adhesive product, the adequate technique for application and removal of the medical patch, and teaching professionals and patients.
Taking care of the skin of critically ill patients using medical adhesives is challenging. To do so, the professional must understand the importance of maintaining skin integrity and identify the characteristics of MARSI and the main strategies to prevent those injuries.
It is necessary to highlight that each individual's particularities intensify in the intensive care unit setting: the critically ill patient is more likely to be exposed to medical adhesives because the treatment requires the application of monitoring electrodes, vascular access fixation, and drain fixation, respiratory devices, and dressings. Moreover, patients are exposed to anticoagulants, vesicant medications, corticoids, mechanical ventilation, and tissue hypoxia (1,7,18) .
Considerations about the etiology of skin injuries are relevant to planning and developing strategies to prevent MARSI. Despite the data available in the literature, the professionals are still unfamiliar with the subject, which may be due to the lack of validated care protocols regarding MARSI.

Study limitations
We excluded the terms associated with DAI and friction injury during the research protocol development because they were confounding injuries for MARSI. However, some MARSI can be reported in those studies.